🩺 Record Detail
Patient Info
Transcript
<thead>
<tr>
<th><strong>Original Transcription</strong></th>
</tr>
</thead>
<tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">Doctor</strong>: Good morning, Mr. Sharma. It's good to see you again. How have you been since our last appointment in January?</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="Patient">Patient</strong>: Good morning, doctor. I've been alright for the most part. But over the last month, I've started experiencing some discomfort in my chest when I exert myself. Like walking fast, climbing stairs, or carrying groceries.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="Doctor">Doctor</strong>: I see. Can you describe this discomfort? Is it sharp? Burning? Pressure-like?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="Patient">Patient</strong>: It feels more like pressure. Like a weight on my chest it usually lasts a few minutes and goes away when I sit or slow down.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="Doctor">Doctor</strong>: Have you noticed any accompanying symptoms? Shortness of breath? Lightheadedness? Sweating? Or pain radiating to your arm or jaw?</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="Patient">Patient</strong>: Yes. I do feel a little breathless. Especially if I push myself. No pain in the arms or jaw. Though. And I've had a few episodes where I felt a bit dizzy afterward.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="Doctor">Doctor</strong>: Alright, thank you for sharing that. Let's take a look at your vitals first. Your blood pressure today is 142 over 88. Slightly elevated. Your pulse is regular at 82 beats per minute. And your oxygen saturation is 97%. Any changes in your medication or diet recently?</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="Patient">Patient</strong>: I've been trying to reduce salt and walk 30 minutes daily. But I do sometimes forget my evening dose of amlodipine.</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="Doctor">Doctor</strong>: That could be contributing to the elevated blood pressure. And what about your diabetes? Were you monitoring your glucose levels?</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="Patient">Patient</strong>: Yes. I check it every morning. It's usually around 110 to 120. I haven't started medication yet.</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="Doctor">Doctor</strong>: That's manageable for now. But we need to keep an eye on it. Coming back to the chest discomfort. Based on your symptoms, I'd like to run a few tests. Specifically an ECG. An echocardiogram. And a treadmill stress test. These will help us assess how your heart responds under physical exertion.</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="Patient">Patient</strong>: Okay. Do I need to get them done today?</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="Doctor">Doctor</strong>: We'll schedule them within the next week. In the meantime, I'm going to make a few adjustments to your treatment plan. I'll increase your amlodipine dose to 10mg once daily and start you on a low-dose aspirin. 81mg per day. To reduce the risk of any clot formation. I'll also prescribe a statin to help lower your LDL cholesterol.</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="Patient">Patient</strong>: That sounds like a lot. Will there be any side effects I should watch out for?</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="Doctor">Doctor</strong>: That's a fair concern. You might experience mild fatigue or muscle aches with the statin. But most people tolerate it well. The aspirin can occasionally cause gastritis. So I'll prescribe a gastroprotective medicine along with it. Let me know if you experience any black stools, stomach pain, or unusual bruising.</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="Patient">Patient</strong>: Understood. Should I avoid any particular foods?</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="Doctor">Doctor</strong>: Yes. Continue your low-sodium diet. Reduce saturated fats. And increase intake of vegetables, legumes, and lean protein. Avoid smoking and limit alcohol. Hydration and consistent physical activity are important too. Preferably brisk walking. But don't overexert yourself until we complete the stress test.</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="Patient">Patient</strong>: I'll try my best. What about follow-ups?</p></div></td></tr><tr><td id="fragmentid_19"><div><p><strong class="Doctor">Doctor</strong>: We'll see you again in two weeks once the test results are in. My team will call you to book the diagnostic appointments. In the meantime, if you experience severe chest pain, shortness of breath, or feel faint, please go to the emergency room immediately.</p></div></td></tr><tr><td id="fragmentid_20"><div><p><strong class="Patient">Patient</strong>: Thank you, doctor. This was very helpful.</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="Doctor">Doctor</strong>: You're welcome. We'll stay proactive and make sure everything is under control. I'll have the nurse explain the prescriptions and testing schedule before you leave.</p></div></td></tr></tbody>
Clinical Notes
Symptoms : Chest discomfort during exertion, described as pressure-like, lasting a few minutes and relieved by rest. Accompanied by shortness of breath and occasional dizziness.
Findings : Blood pressure at 142/88 mmHg, pulse regular at 82 bpm, oxygen saturation at 97%.
Medical History: Patient has been experiencing chest discomfort over the last month during physical exertion. Has a history of elevated blood pressure and is currently on amlodipine, though sometimes misses the evening dose. Blood glucose levels are monitored daily, ranging from 110 to 120 mg/dL. No diabetes medication started yet.
Medicines : - Amlodipine increased to 10mg once daily - Low-dose aspirin 81mg per day - Statin prescribed for LDL cholesterol management - Gastroprotective medicine to accompany aspirin
Diagnosis : Potential cardiac-related chest discomfort. Elevated blood pressure.
Investigation : ECG, echocardiogram, and treadmill stress test to be scheduled within the next week.
Instruction : Continue low-sodium diet, reduce saturated fats, increase intake of vegetables, legumes, and lean protein. Avoid smoking and limit alcohol. Maintain hydration and consistent physical activity, preferably brisk walking, but avoid overexertion until stress test is completed. Watch for side effects such as fatigue, muscle aches, gastritis symptoms, black stools, stomach pain, or unusual bruising.
Follow up : Follow-up appointment in two weeks after test results. Immediate emergency room visit advised if severe chest pain, shortness of breath, or faintness occurs.